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The authors respond

No, the problem is not unique to your hospital alone! The situation you describe in your letter is due to 2 complexities in hospital nursing practice that are increasingly being recognized. And, thanks to managers and clinical nurses in Magnet and other "excellence-recognized" hospitals and clinical units, evidence-based practices useful in dealing with these complexities are being identified and implemented.

The Simultaneity complexity—care for multiple patient simultaneously —has long been recognized as unique to the professional nursing practice of clinical nurses in hospitals. In contrast to medicine, law, and other professions in which the client-practitioner relationship is based on sequential care to one client at a time, clinical nurses are expected to care for 2 to 5 patients simultaneously. Unlike some professions (teachers in classrooms, lawyers in class-action suits, or pastors with their parishioners) in which the client-practitioner relationship is based on groups of similar clients with similar needs, nurses must care for multiple, diverse clients with different and rapidly changing conditions and needs.

In relation to the situation you describe in your letter, medical-surgical intensive care unit (ICU) nurses are most susceptible to the fallout from unmanaged, unrecognized Simultaneity complexity. The nurse-patient ratios in all ICUs are increasing but medical-surgical ICU nurses face the most diverse of all client populations and, in a recent study reported in Critical Care Nurse,¹ medical-surgical ICU nurses reported one of the least healthy work environments.

The second complexity described in your letter is Complexity Compression present in all professions. Nurses, as well as all other professionals, must enact multiple professional role responsibilities, many of which are not directly related to the dominant caregiving. In addition, they must enact these responsibilities—research and evidence-based practice initiatives; mentoring of newcomers; group activities designed to control the context of professional practice; increased documentation; keeping up with massive and ever changing drugs, procedures, and legalities; and maintaining up-to-date competence in one’s field of practice—within a compressed time frame. In a state-wide study of clinical nurses in Minnesota, Krichbaum et al² report that as much as 40% of a clinical nurse’s work day is consumed by such peripheral role responsibilities.

In addition to the responsibilities cited above, you mention an additional complexity that ICU nurses must contend with, that is, responding to hospital codes and serving on rapid response teams. Increasingly, attention and research are being devoted to identifying structures, strategies, and practices that will ameliorate the stress caused by simultaneously meeting care needs of multiple patients and enacting peripheral professional roles and responsibilities within available time. First of all, these work complexities faced by clinical nurses in hospitals must be recognized and understood by nurses and hospital leadership for what they are. They are the context within which professional nursing in hospitals is practiced; they are not due to practitioner incompetence or to "being new" to the profession.

Following recognition, strategies, structures, and systems for alleviation of the problems caused by the complexities can be instituted. For example, clinical nurses and nurse managers can specifically address the issue of codes and rapid response team responses. When these events happen, what strategies are to be used? If the staff nurse does not return to the unit within 30 minutes, then what? If the strategies developed do not resolve the problem, new strategies will need to be developed and tested. Unless and until leadership and clinical nurses work together, the problems engendered by simultaneity and compression complexities will never be resolved.

Dealing with work complexities will not solve continual and increasing erosion in numbers of qualified nurses for the acuity level of the patients—another of the problems you cite in your letter. With the RN shortage projected to continue, with increasing cost-cutting measures, appropriate numbers of nurses will continue to be an issue. Conflict resolution principles would dictate that you not only have general discussions about staffing problems but that when the situation arises, you get your nurse manager and nursing leadership involved to answer your question "where do we go from here?" Not just once, but each time it happens! This may or may not result in more staff, but at the very least, strategies to provide the quality of care that patients need and you want to provide should be forthcoming.

References

1. Schmalenberg C, Kramer M. Clinical units with the healthiest work environments. Crit Care Nurse. 2008;28(3):65–77.[Free Full Text]
2. Krichbaum K, Diemert C, Jacox L, et al. Complexity compression: nurses under fire. Nurs Forum. 2007;43(3):86–94.

This Article Full Text (PDF) PDF (OnlineFirst) Respond to This Article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Google Scholar Articles by Schmalenberg, C. Articles by Kramer, M. PubMed PubMed Citation Articles by Schmalenberg, C. Articles by Kramer, M.